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Yoga Therapy Registration 

For new Yoga Therapy clients. Please take time to complete this form before our first session.

On a scale of to 5, how would you rate your current PHYSICAL well being? (Poor - 1 to Excellent - 5)
On a scale of 1 to 5, how would you rate your current MENTAL & EMOTIONAL well being? (Poor - 1 to Excellen - 5)
Do you consider yourself as someone who experiences sensory challenges at all? (e.g, sensitive to certain noises, light, textures, etc)
Take a look at the health issues below and tick any that you are currently experiencing, or have experienced in the past that you feel may be relevant for your course of Yoga Therapy.
DATA PERMISSIONS:Your details will be held securely in compliance with the Data Protection Act and will not be shared with any third party.

Thanks for submitting!

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You will receive a FREE Seasonal Self-care Bundle, plus an extra BONUS Gift too.

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